Oral- Motor & Feeding

Question 1

Oral Structures Involved with Oral-Motor Control

Answer 1

Complex coordinated control of hand to mouth, lips, jaw, tongue, cheeks

• Oral cavity: hard & soft palate, tongue, fat pads, upper & lower jaw and teeth; contains food during drinking and chewing; provides mastication before swallowing
• Pharnyx: base of tongue, buccinator, hyoid, oropharnyx; funnels food into esophagus, allows food and air to share the same space
• Larynx: epiglottis and false/true vocal folds; valve to trachea, closes during swallow
• Trachea: tube that allows air to flow to bronchi
• Esophagus: tube that carries food from pharnyx to stomach

Infant Oral Structures

• Small oral cavity
• Fatty cheeks
• Epiglottis & soft palate approximation
• Small jaw, pulled back

Adult Oral Structures

• Oral cavity larger, more open
• Larger jaw, positioned forward
• Cheeks no longer have fatty pads
• Hyoid & larnyx more mobile

Question 2

Sucking & Drinking Patterns

Answer 2

2 Types of sucking patterns

• Nutritive- taking a draw from bottle to swallow
• Non-nutritive- same but shorter

Development of sucking patterns:

• Suckling: 0-4 months: forward-backward movement of the tongue, up & down movement of the jaw, some liquid loss and intake of air (that’s why you burp babies)
• 6 months: jaw stability improves, tongue movement improves with strong up & down pattern; has lip seal and minimal liquid loss; uses suckling pattern on new stimulus (cup)
• 9-12 months: strong sucking patterns on bottle; uses up & down jaw motion with cup( messy); can’t stabilize jaw on rim of cup
• 18 months: transition to cup, uses external jaw stabilization by biting on rim of cup
• 24 months: efficient cup drinking; can use lips while cup drinking, internal jaw stabilization; no liquid loss, lengthy suck-swallow

Question 3

Development of Biting & Chewing Patterns

Answer 3

• 0-4 months: biting patterns are reflexive
• 4-5 months: phasic bite and release, up & down pattern on items put in mouth: “munching”
• 7-8 months: emergence of diagonal movement of jaw in response to changes in food textures; bite and hold cookie wt jaw; tendency to suck instead of bite through; active upper lip to clear spoon when eating from spoon
• 9 months: up, down & diagonal jaw movements; lateral tongue movements to transfer food to side of mouth, munching pattern on soft table foods
• 12 months: rotary jaw movements emerge; can bite through soft cookie, active tongue movements (lateral, lick top and lower lips at midline)
• 18 months: coordinated rotary chewing; can bite through hard cookie and pretzel
• 24 months: graded bite to be able to bite through hard foods; able to eat most meats and raw vegetables; lip closure during chewing to prevent food loss, tongue can clear lips on all sides

Question 4

Coordination of Suck, Swallow, Breathe

Evaluation/Assessment of Oral-Motor & Feeding Skills

Answer 4

• Pre-Oral Phase
• Oral Phase
• Pharyngeal Phase
• Esophageal Phase
• Coordination of Pre-Oral and Oral Phase develops from birth to ~18 months

Interview

• Parent concerns
• Medical history
• Family routines at home
  
  • Utensils used
  • Favorite foods
  • Positioning
• Child’s gross- & fine-motor skill abilities

Observation & Context

• Physical:
  
  • Positioning & postural alignment?
  • Equipment/utensils used
  • Sensory
• Social: who is feeding child? Who is present? Communication& Interaction?
• Temporal: time, frequency
• Cultural
• Naturalistic as possible; Relaxed atmosphere
• Positioning of child: How does parent hold & position the child?
• Parent demonstration of a typical feeding situation (observe parent-child interactions)
• Watch for child’s oral-sensitivity
• What is child’s postural control?
• Watch for jaw, lip, tongue movements & coordination
• What is child’s strength & endurance for feeding?
• Option: Videofluoroscopic swallow study (modified barium-swallow)

Question 5

Medical Conditions that can affect oral-motor & feeding skills?

Answer 5

• Bronchiopulmonary Dysplasia
• Gastroesophageal Reflux (GER)
• Congenital Heart Disease
• Tracheoesophageal fistula (misconnection between trachea & esophagus
• Esophageal atresia (no connection or dead end of esophagus)
• Oral-Facial Anomalies (cleft lip, cleft palate, syndromes)

Question 6

Feeding Issues most often addressed by OT?

OT Intervention with Sensory-Based Feeding Issues?

Answer 6

• Sensory issues that lead to developmental delays or behavioral issues in feeding
• Motor issues that lead to oral-motor coordination issues
• Psychological issues without motor or sensory issues that lead to behavioral issues in feeding

Major Issues:

• Adverse reactions to touch and/or textures in/around the mouth OR
• Reduced awareness of food in or around the mouth
• Leads to social interaction & behavioral issues, delay in oral-motor skill development

Possible Causes:

• Negative oral experiences as an infant
• Extended period of non-oral feeding
• Sensory modulation issues
• Hyper OR hypo-responsiveness

OT Intervention with Sensory-Based Feeding Issues

Intervention Strategies:

• Sensory activities at other times than meal-time or before mealtime
• Encourage oral exploration if developmentally appropriate
• Deep Pressure activities
• Use of oral-motor toys & games (whistles, blowing through straw, etc.)
• Food placement

Question 7

OT Intervention with Motor-Based Feeding Issues?

Answer 7

Hypotonia:

• Head & trunk control issues, lack of stability; poor alignment
• Inefficient jaw stability
• Poor ability to grade movement
• Open mouth posture; increased drooling
• Inactive tongue
• Inactive lips, poor lip closure

Hypertonia:

• Poor head & trunk control with a tendency toward neck hyperextension
• Abnormal oral-motor patterns (tonic bite, jaw thrust, etc.)
• Poor coordination of suck-swallow-breathe
• Increased drooling

Swallowing Disorders:

• Poor coordination of suck-swallow-breathe
• Oral transit of food slow
• Pooling of food in pharnyx
• Delay of swallow reflex
• Increased risk of aspiration
• Respiratory issues

Intervention Strategies:

• Postural alignment & stability
• Handling/facilitation techniques to support oral-motor control
• Pacing of feeding
• Thickening of foods

Question 8

OT Intervention with Behavioral Feeding Issues?

Answer 8

• Work with psychology or counseling program
• Thorough evaluation to rule-out sensory or motor-based issues
• Determine foundation of behavioral issues

Strategies:

• Work with family:
• Start with small amounts of food first
• Start with familiar and allow time for child to adapt to new foods
• Behavior diaries
• Self-concept activities
• Behavior management
• Child participation
• Context!!
• The amount of time it takes to feed a child
• Nutritional issues
• Nutritional consult

Question 9

Use of Food Textures in Intervention?

(See page 404 in Case-Smith & O’Brien (2015)

Answer 9

• Foods for spoon feeding: sequential suggestions (easy to more difficult)
• Pureed foods: yellow vegetables like squash and carrots; blended bananas; pear or apple sauce; baby cereals
• Pureed foods: green vegetables like peas, beans, spinach; thickened or chunky applesauce, thickened baby cereals
• Pureed meats
• Fork mashed table foods
• Varied texture and food combinations: stews (juice and chunks of food); pasta dishes; cereal and milk, soup with vegetables

Chewing Skills: Easy to difficult:

• Soft: chunks or strips of banana, mango, soft pears
• Soft, firm: cooked, steamed vegetables like carrots, green beans, zucchini, potato strips; cucumber, apple slices without skins, cheese strips, cooked pasta, cooked pinto beans or other beans
• Soft, fibrous: strips of cooked chicken & turkey, roast beef & ham, rice
• Firm: melba toast, toast, crackers, graham crackers, soft cookies, cheese puffs
• Firm, chewy: dried fruit, orange slices, fruit roll-ups, jerky
• Hard: hard cookies, pretzels, hard crackers, nuts
• Hard, chewy: raw celery, raw carrots, apple or fruit slices
• Thicker liquids (milk shake, smoothie): easier to control when swallowing
• Thin, runny liquids (clear juices, water): harder to control when swallowing
• See page 404 in Case-Smith & O’Brien (2015) for terms related to liquid consistencies:
• Thin consistency-Nectar consistency-Honey consistency
• To thicken food: “Thick-it”, pudding powder, yogurt, apple sauce
• Milk products have a tendency to increase mucus (could affect swallowing)
• Sweets have a tendency to increase saliva (could increase drooling)
• For texture-sensitive children: make sure textures are consistent and change all textures slowly, over time

Question 10

Non-Oral Feeding

Answer 10

Failure to Thrive or Pediatric Under-Nutrition

Types:

• Naso-gastric tube
• Oral-gastric tube
• Gastronomy tube or button
• Tubes leading to the intestines (J-tube)
• Hyperalimentation (central line with nutritional supplements directly into bloodstream)

Transition from Non-oral feeding to Oral feeding

Getting ready:

• Activities to desensitize areas around the mouth: (tapping cheeks, chewing or biting rubber toys or wash cloths, blowing bubbles, blowing or giving kisses)
• Food texture play with hands to mouth for tastes (not at mealtime)

Beginning the transition:

• Bolus feeds at paced intervals instead of continuous feeding to allow feeling of hunger and satiation to return
• Give bolus feed 3 - 4 times a day to simulate mealtimes
• Before the bolus feeding by tube, allow child to take some of the food by mouth

Transition:

• Slowly decrease amount in bolus feeds in tube and increase amount of oral feeds
• Eliminate one bolus feed and substitute with oral feed
• Eventually eliminate all bolus feeds
• The process may take a long time